emergency contraception, quick start & a bit about larcs dr jackie abrahams...

Emergency Contraception, Quick Start & a bit about

LARCS

Dr Jackie [email protected]

Pregnancy and Emergency Contraception (EC)

‘All women of reproductive age are pregnant until proven otherwise’

Think about possibility of pregnancy or need for EC

With every request for contraception With every request for a pregnancy

test. With any other consultation

Emergency Contraception

Remember

There is a failure rate with Levonelle 1500 and EllaOne

There is virtually no failure rate with postcoital

(PC) Coil.

All women should be offered the option of PC Coil (especially if they are mid cycle and/or over 48 hours)

4

ellaOne vs Levonelle

ellaOne more effective (failure rate 1.28% compared to 2.2% with Levonelle)

ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48 hours pre-ovulation

ellaOne licensed for use up to 120 hours post UPSI and equally effective throughout that time period

ellaOne is a Progesterone Receptor Modulator and therefore interferes with ongoing hormonal contraception for the next 7 days

NB No evidence that either have much effect after ovulation

ellaOne vs Levonelle

ellaOne more expensive - £16.95 vs £5.20 Approved by Joint Area Prescribing Committee

(JPAC) for women under 35 who are mid cycle

(ovulation minus 6 days to ovulation plus 2 days)

For women presenting for EC between 73 and 120 hours post UPSI


Over 72 hours? – PC Coil best option- up to 5 days after earliest ovulation (i.e., day 19

of a regular 28 day cycle) – regardless of how many episodes unprotected sexual intercourse (UPSI).

- If beyond ovulation+5days - up to 5 days after UPSI

Unlicenced Use Levonelle 1500 or EllaOneIf coil not an option, can have Levonelle-2 or EllaOne as unlicensed use over same timescale as PC Coil (but much higher failure rate)


And then ?QuickstartIf starting hormonal method consider

immediate start oral contraception small risk of pregnancy but ?worth it.

- COC - not safe for 7 days after Levonelle – 14 days after EllaOne

- POP – not safe for 2 days after Levonelle – 9 days after EllaOne

- PT with EMU in 3-5 weeks – ideally PT 3 weeks after last risk (eg 5 weeks after EllaOne and quickstart COC as not protected by COC for first 2 weeks)


Missed Pills Take Levonelle and continue with pills

(don’t stop and wait for next period – it might never come!)

Do Pregnancy test 3-4 weeks later (whether or not normal withdrawal bleed)

NB Levonelle better than EllaOne for missed pills (because of effect on progesterone receptors with EllaOne)

Late / Missed Pills

COC Latest FPA Guidance (what we teach the patients)

can miss 1 pill anywhere in pack – no extra precautions needed

If miss 2 or more need extra precautions and active pills for 7 days

‘pragmatic’ guidance (what we know) Need to have taken 7 active pills can miss up to 7 anywhere else in pack need 7 active pills after missed pills

NB Extra precautions not needed with antibiotics

POP – Only need extra precautions until normal pill taking resumed for 48 hours (Late = 12

hours for Cerazette, 3 hours for other POP’s)

Late Depo Injection

Up to 14 weeks – give next Depo. No extra precautions needed

14 – 15 weeks – give next Depo. If any UPSI after 14 weeks also give PCC (Levonelle or PC IUD). Not safe for 7 days and need PT in 4 weeks

Over 15 weeks – need to exclude pregnancy before rpt Depo – unless no UPSI after 14 weeks (?COC or POP for 1 month and then next Depo with neg PT)(according to most recent WHO guidelines can have repeat Depo up to 16 weeks and don’t need extra precautions for 7 days – UK Guidelines still say 14 weeks)

Quick Starting Contraception

Clinical Effectiveness Unit September 2010

See Faculty website http://www.fsrh.org.uk for full

guidelines

Quick Starting Contraception Key Recommendations

If a health professional is reasonably sure that

a woman is not pregnant or at risk ofpregnancy from recent unprotected sexual intercourse (UPSI), contraception can bestarted immediately unless the woman

prefersto wait until her next period.


If pregnancy cannot be excluded (e.g. following administration of EC) but a woman is likely tocontinue to be at risk of pregnancy, immediate‘quick starting’ of CHC, the POP or progestogenonly implant may be considered. The woman should be informed of thepotential risks and the need to have apregnancy test at the appropriate time.


Women requesting the progestogen-only

injectable should ideally be offered abridging method if pregnancy cannot

beexcluded, but immediate start isacceptable if other methods are notappropriate or acceptable.


If contraception is quick started in awoman for whom pregnancy cannot beexcluded, a pregnancy test should be advised no sooner than 3 weeks after

thelast episode of UPSI.


If starting hormonal contraception immediately after ulipristal acetate

EC,the CEU recommends condoms oravoidance of sex for 14 days (9 days ifstarting POP, 16 days for Qlaira)

LARC’sLong Acting Reversible

Contraceptives

IUD/IUS Progesterone subdermal

implant (Nexplanon) Depoprovera

IUD/IUS

Key MessagesJust as good for Nullips as MultipsNo need for swabs with every fit

Do STI risk assessment and decide if necessary

If taking swabs only need to do 2 endocervical swabs for GC and Chlamydia

(an HVS is a diagnostic test – only necessary if has abnormal discharge)

IUD vs IUSIUD

Less problems than IUS if normal/light periods

Can be fitted up to ovulation + 5 days regardless of whether UPSI since LMP

If fitted over age 40 can stay in until menopause

Most effective emergency contraception

IUS 1st choice if heavy

periods or had heavy periods with IUD

Amenorrhoea in only 25-30%

Can cause significant bleeding problems for up to 6 months

Other progesterone side effects

Cannot be used for emergency contraception

Nexplanon

Most effective contraceptive method Failure rate 1/2000 No serious risks Main challenge is management of

side effects Bleeding problems Mood swings Skin problems

Bleeding Problems with Nexplanon

Don’t usually need any investigation apart from STI risk assessment and/or screening

Usually respond to COC or POP Often settle after 3 months of

treatment If recur on stopping can continue COC

or POP longterm

DCHS Sexual Health Service Clinics

Central Booking Line for all Appointments Tel 01246 235792

We will accommodate requests for Emergency IUD’s at all of our clinics

Contact numbers to speak to a clinician Dr Jackie Abrahams 07967 729253 Dr Stephen Searle 07774 962320

Diploma of the Faculty of Sexual and Reproductive Healthcare

(DFSRH)

Details of the training requirements for DFSRH and Letters of Competence (LoC’s) in Intrauterine Techniques and Subdermal Implants are available on the Faculty website http://www.fsrh.org/pages/Diploma_of_the_FSRH.asp

DFSRH training involves three stages: e-learning for theory background; the e-SRH programme Course of 5; five hours of small group workshops Clinical experience and assessment

Course of 5 and Practical Training

Locally training is organised through

Course of 5 is run twice a year – next one is on 17th June 2013

Details of training elsewhere in UK is available on the Faculty website

Training for Health Department Phone: 01246 868448Email: [email protected]: www.trainingforhealth.derbys.nhs.uk

emergency contraception, quick start & a bit about larcs dr jackie abrahams...

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